At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?
Constipation
Indigestion
Swollen ankles
Urinary frequency
None
None
The Correct Answer is B
A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.
B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.
C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."
D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Notifying the facility operator is important, but it is not the immediate priority when there is a fire endangering the client's safety.
B. While closing fire doors can help contain the fire, it is not the priority action after ensuring the client's immediate safety.
C. Turning off oxygen sources is crucial because oxygen can fuel the fire and cause it to spread rapidly. This action helps prevent the fire from worsening.
D. Putting out the fire with the appropriate extinguisher is important, but it comes after ensuring the fire's fuel source is cut off to prevent further escalation of the fire.
Correct Answer is D
Explanation
A. Detaching the needle from the syringe before discarding it increases the risk of needle-stick injuries. Needles should be disposed of as one unit to minimize the risk of injury.
B. Broken glass should be disposed of in a puncture-proof container to prevent injuries. Placing it directly in a wastebasket increases the risk of puncture injuries to individuals handling the waste.
C. Recapping needles increases the risk of needle-stick injuries. Needles should not be recapped after use unless there is no safer alternative. Instead, they should be disposed of as one unit.
D. Lancets, needles, and other sharp objects should be placed in puncture-proof containers immediately after use to prevent injuries. This practice helps ensure the safety of healthcare workers and others who handle waste.
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